Provider tools and resources

Council for Affordable Quality Healthcare (CAQH)

Save time on filling out multiple forms by completing the CAQH credentialing application kit. It's entirely free to providers and helps practices save money on administrative resources. Complete your application kit on the CAQH website.

Learn more about our credentialing criteria for professional providers.

Network Participation and Credentialing

Thank you for your interest in becoming a participating provider at AmeriHealth New Jersey.

Professional Providers

Professional providers include but is not limited to the following specialties: physicians, radiologists, CRNP, physical therapists, registered dieticians, etc.

Most licensed practitioners are board-certified physicians. If a physician is not board certified, the required number of educational years deemed sufficient per the Accreditation Council for Graduate Medical Education (ACGME) guidelines would need to be primarily source verified. There are some instances where a practitioner is not board certified, and the educational institution per their policy requires a payment for the verification of a completed program. As needed for cases where education requires a charge, AmeriHealth New Jersey will place the responsibility on the practitioner for the required verification from the institution to be sent directly to the Credentialing Operations processor.

All providers interested in participating must complete the Practitioner Participation Form.*

Important credentialing notes

  • Any professional provider interested in participating in our network must complete the Practitioner Participation Form.
  • Any credentialing application request not received through the Practitioner Participation Form will be returned with instructions to submit the request using the form.
  • The Practitioner Participation Form is only for credentialing applications.
  • Certified registered nurse practitioners (CRNP) must have a collaborative agreement with a participating physician who holds a current and unrestricted license. The training and scope of practice of the collaborating physician must be consistent with the practice of the CRNP. To see scenarios where CRNPs are only allowed to be contracted and credentialed with AmeriHealth New Jersey, please read this article.

Note: Behavioral Health Providers

AmeriHealth New Jersey currently works with Magellan Healthcare, Inc. (Magellan) to provide a behavioral health network to its members. Effective January 1, 2023, we are insourcing the network and are directly contracting with behavioral health providers.

If you have not yet signed an AmeriHealth New Jersey Professional Provider Agreement but are currently participating with Magellan, you will be considered in-network for our members and will continue to be reimbursed according to Magellan’s reimbursement terms. If you would like to receive an enhanced reimbursement under the terms of the AmeriHealth New Jersey agreement, please follow the process outlined below.

If you are a behavioral health provider interested in joining our network:

  • If you do NOT currently participate in the Magellan network: The first step is to complete the Practitioner Participation Form.
  • If you currently participate in the Magellan network but have NOT signed an AmeriHealth New Jersey Professional Provider Agreement: To obtain a contract, you must submit an application through credentialing. This enables us to verify your credentials with Magellan and then issue you a contract.
  • If you currently participate in the Magellan network and have signed an AmeriHealth New Jersey Professional Provider Agreement: You do NOT need to do anything. Your current credentials will remain in effect on January 1, 2023. If you are scheduled to be re-credentialed in 2023, Magellan (on behalf of AmeriHealth New Jersey) will perform recredentialing and pass the results to AmeriHealth New Jersey. Please be sure to respond to all recredentialing requests to ensure continuous participation. If you are a participating practice, please make sure that your practitioner roster is up to date.

Behavioral health practitioners joining existing contracted groups

  • If you have a new practitioner joining a Contracted Group contracted with Magellan, or contracted with both Magellan and AmeriHealth New Jersey, please submit all credentialing material to Magellan.
  • If you have a new practitioner joining an AmeriHealth New Jersey contracted group that does not contract with Magellan, initiate the credentialing process at AmeriHealth New Jersey by completing the Practitioner Participation Form.

Note: While AmeriHealth New Jersey transitions to a directly contracted behavioral health network, behavioral health providers contracted with Magellan will continue to be considered in network through 2023. If you have any questions related to your Magellan agreement, you can contact Magellan Provider Services Line at 1-800-788-4005 for assistance.

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most AmeriHealth New Jersey members.

Reimbursement terms effective January 1, 2023:

  • If you currently participate in the Magellan network but have not signed an AmeriHealth New Jersey Professional Provider Agreement, you will be considered as participating in the AmeriHealth New Jersey network and will be reimbursed in accordance with the terms and conditions specified in the Magellan Professional Provider Agreement.

    While you will maintain your in-network participation status to provide services to AmeriHealth New Jersey members, you will not be eligible for the AmeriHealth New Jersey terms and conditions (including provider appeal rights and the enhanced AmeriHealth New Jersey reimbursement) until you sign an AmeriHealth New Jersey Professional Agreement.

Please refer to the steps above to complete the contracting/credentialing process.

New accreditation requirements: Office-based varicose vein procedures

Effective June 1, 2019, all network offices that perform varicose vein procedures will need to obtain office-level accreditation from the Intersocietal Accreditation Commission (IAC) Vein Center. All network offices that plan to perform or would like to continue performing varicose vein procedures must appear on the IAC-approved list for Vein Center Accreditation by June 1, 2019, indicating that they have met the IAC standards. Those offices who fail to meet the requirements by this date will no longer be reimbursed for varicose vein procedures.

To learn more about the IAC Vein Center accreditation program, please visit the IAC website or call 1-800-838-2110. If you have additional questions, please email us at qualitymanagement@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email.

Keep Your Information Current

Keeping your practice information up-to-date isn’t just important for credentialing purposes — it’s important for health plan records and directories, too. The CAQH ProView® online application makes it quick and easy for you to stay current by allowing you to update only the information that needs to change. There’s no need to resubmit information that should stay the same.

In addition, it is important that you notify your Provider Partnership Associate if you’ve made changes to any of the following:

  • your mailing address
  • your phone number
  • name of your practice
  • your office hours
  • your acceptance of new patients
  • your plan to dissolve your practice

To make any change to your information, please use the appropriate form below:
Participating Provider Change Form
Non-Participating Provider Change Form

All Magellan providers must use Magellan’s online Provider Data Change Form to update their practice data.

Keeping your practice data up-to-date in Magellan’s system facilitates appropriate member referrals, accurate claims processing and timely correspondence. By making regular monthly updates, you will help ensure that members have access to your most recent information, including appointment availability, when searching for a provider.

To review and update your practice information:

  • Visit www.MagellanHealth.com/provider
  • Sign in with your username and password (Select Forgot Password? or Forgot Username?, if you need to obtain your log-in information)
  • Select Display/Edit Practice Information from the left-hand menu
  • The first tab that displays is the Provider Data Change Form

Need Assistance?

Refer to the Help text that accompanies the online form, listen to a recorded webinarLINK, or check out Magellan’s Provider Data Change Form demo.

Compliance Training for Medicare Programs

AmeriHealth New Jersey is committed to compliance with the Medicare Advantage Program, as required by the Centers for Medicare & Medicaid Services (CMS). CMS requires that all first-tier, downstream, and related entities (FDR) complete the following courses, which are available through the Medicare Learning Network (MLN):

  • Medicare Parts C and D General Compliance Training
  • Combating Medicare Parts C and D Fraud, Waste, and Abuse

An FDR is defined by CMS as a party that enters into a written agreement to provide administrative services or health care services to a Medicare enrollee on behalf of a Medicare Advantage or Part D plan. FDRs include, but are not limited to, contracted health care providers, pharmacies, and vendors.

As a provider of health care services for AmeriHealth Medicare Advantage and Medicare Part D Prescription Drug Program (Medicare Part D) members, you and your staff are expected to comply with CMS requirements by completing Medicare compliance training on an annual basis.

Please visit the Centers for Medicare & Medicaid Services directly to access and complete your Medicare compliance training at the time of hire and annually thereafter. We suggest that you and your staff maintain records of completion.

Provider News Center

Visit our Provider News Center for timely and critical updates on administrative processes, pharmacy services, preventive health, and other important information.

Provider Demographic Changes

A one-stop reference page that provides the designated methods for the submission of demographic changes.

Provider Automated System

Our speech-enabled Provider Automated System is an enhanced phone service that can be used to complete some administrative tasks, such as:

  • eligibility
  • benefits
  • claims
  • authorizations

The Provider Automated System allows you to either speak your responses or enter them using your telephone keypad. Within minutes, you can obtain information about your patients. To connect to the Provider Automated System, call 1-888-YOUR-AH1 (1-888-968-7241).

Download the Navigating the Provider Automated System guide for tips and instructions for completing the transactions available through the Provider Automated System.

Office Administration/Patient Education Resources Order Form

Request items to assist your office in seamlessly working with and treating your patients. Fill out our online form.

*All information obtained during the credentialing process is confidential and will not be shared with third parties. Submission of the credentialing application and required supporting documentation does not guarantee inclusion in AmeriHealth New Jersey network(s).

The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.